Provider Demographics
NPI:1265446017
Name:TACK, PAUL C (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:TACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:501 N RIVERSIDE DR
Mailing Address - Street 2:SUITE 216
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5918
Mailing Address - Country:US
Mailing Address - Phone:847-625-8300
Mailing Address - Fax:847-625-8862
Practice Address - Street 1:501 N RIVERSIDE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5918
Practice Address - Country:US
Practice Address - Phone:847-625-8300
Practice Address - Fax:847-625-8862
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036097015207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211292Medicare ID - Type Unspecified
ILG93759Medicare UPIN